Gradually we are coming to appreciate that we have an ethical responsibility for good health, and it is even receiving a religious sanction, for we have come to know that the cause of evil behavior may be due primarily to an unsound body rather than to a perverted soul. The church has ever ministered to the sick and has supported hospitals, but to-day it is commencing to advocate the prevention of disease through sanitation and hygiene, and to preach the religious duty of fostering health and preventing sickness.
One of the principal factors in the farmer's relative indifference to health measures is the fact that he has become accustomed to think that an outdoor life and isolation from other people give him an ability to withstand sickness and he has rather gloried in his ability to throw off ordinary ailments and to withstand the physical hardship which his work often demands. He can see how health conditions may need attention in the city where people are crowded together, but he is not impressed that other causes make such diseases as typhoid and malaria much more prevalent in the open country, and that bad sanitation on a farm a mile away may cause sickness in his own family. American farmers have been educated on the nature and spread of disease by their experience with animal diseases, such as bovine tuberculosis, hog cholera, and Texas fever. If they can be interested to utilize this knowledge in the care of the health of their own families, and if they will provide health facilities for their own families equal to those which they feel necessary for their livestock, health conditions on the farm will show rapid improvement. It is not that the farmer is indifferent to the health of his family, but he has been forced to have his herd tested for tuberculosis, and he faces the possibility of heavy losses if he does not have his hogs vaccinated for cholera, while he has not appreciated that by preventative agencies the better health of his wife and children may be insured and the cost of remedial treatment be greatly lessened.
The purely economic aspects of sickness and disease have been a potent factor in the health movement, particularly in cities. The vast sums invested in life insurance have led progressive insurance companies into extensive campaigns for promoting public health so that their risks may be reduced. Vast quantities of the best health literature have been distributed by some of the industrial insurance companies and they have done much to demonstrate the value of public health nursing by employing nurses who visit their policy holders. The extension of the insurance method to health insurance, and the adoption of insurance by large corporations for their employees has furthered this general movement, and has revealed the tremendous economic losses due to preventable sickness and disease. The farmer has failed to appreciate the purely economic handicap under which he labors as a result of sickness and the lack of adequate medical service and efficient public health administration such as cities enjoy, because the cost of sickness is distributed and is borne by each family and he has no means of knowing the aggregate cost for the whole community. Were it possible for a rural community to secure and have brought to its attention the total economic loss due to sickness in a given year and the proportion which might be preventable with a reasonable expenditure for better health facilities, its people would doubtless become as interested in better health administration as does the employer in a large city industry, and the true economy of better health facilities would be apparent.
Few concrete studies of the losses occasioned by sickness in rural communities have been made, but one of Dutchess County,[54] New York, in 1915 well illustrates the conditions which would doubtless be found in many another rural county. This survey covered five districts of the county with an aggregate population of about 11,800—most of which was rural territory. 1,600 cases of serious illness were found to have occurred during the year. "Some 9,000 days were lost by men and women of working age (15 to 54 years). Children lost 13,700 school days. On the average this cost the community for each child at least 33 cents a day for which it received no return. These two items safely represent a money loss of $20,000 to $25,000." As a result of the study it was estimated that the total money loss occasioned by sickness in a year within the whole county would be at least $412,000. "Of the 1,600 patients whose care has been analyzed in this report, 72 percent could have been cared for adequately in their own homes had there been available medical and nursing service. The remaining 28 percent (442 patients) could not have been cared for adequately in their own homes ... 24 percent of the patients secured no medical care. Many startling instances of unnecessary and indefensible suffering and misery were found.... Of the 113 women who went through childbirth in their homes, only one had the continuous care of a graduate nurse, and only 18 had any service whatever from graduate visiting nurses. 35 percent of the children born came into the world under unfit conditions and surroundings." Largely as a result of this study, Dutchess County now has an efficient county health association through which a number of public health nurses are employed, who visit all districts of the county.
One of the most serious handicaps in maintaining the health of the rural community is its frequent lack of medical service. The number of doctors practising in the open country was always inadequate, but in recent years it has decreased until now many large sections are without any resident physician. The influenza epidemic of 1918, following the shortage of doctors during the war, revealed the plight of many a rural community without medical service. The higher standards now required by medical colleges and state licensing boards has resulted in a real shortage of physicians and the young men are not going into the country to practise. A recent study made by the New York State Department of Health showed that in 20 rural counties 88 percent of the physicians had been practising over 25 years and only 3 percent less than ten years. This means that most of the rural doctors in these counties have less than ten years more to practise and that there is no indication that their places will be filled by younger men. In Manitoba one rural municipality has employed a physician on full time, and a recent act of the New York legislature makes it possible for towns to employ physicians. It seems probable that country people will be forced to employ physicians on a salaried basis if they are to secure adequate medical service. This does not necessarily mean, however, that the physician will be employed by the local government. Industrial workers are now employing physicians on a salary and farmers' organizations are employing salaried veterinarians. Why cannot a local health association be formed to employ a physician, whose job it will be to keep its people well?
Two factors prevent the larger use of physicians now available. Chief of these is the cost. Farmers handle relatively less actual money than townsmen, and their income is less frequent so that they have less on hand, while the cost of medical attendance is necessarily higher in the country. Fear of running up a bill deters many a farm woman from calling a doctor, when one call might prevent many more later on. The farm home tends to employ a physician only for serious sickness, rather than as a medical adviser who may forestall illness. Another difficulty is one of the physician's own making. The experience is far too common that in cases of immediate need when the family doctor cannot be located, doctors will refuse to attend a case on account of so-called "professional courtesy." It is time that public opinion be aroused so that such cases be brought to the attention of county medical societies with sufficient public opinion to force them to take suitable action. The ethics of every profession must be shaped to meet the needs of those it serves as well as the pocketbooks of its members.
Lack of medical attendance is most serious for the farm mother during confinement, and the mortality of rural mothers during childbirth, as shown by the investigations of the U. S. Children's Bureau, is an indictment of our supposed civilization. When we learn that in a homesteading county in Montana there were 12.7 deaths of mothers per 1,000 births, which is twice the rate for the United States as a whole, which is higher than that of fifteen foreign countries for which statistics were available in 1915, we face a condition which cannot be neglected. When we find that in Wisconsin this rate was but 6 per 1,000, and that 68 percent were attended by physicians, and in Kansas it was but 2.9 per thousand and 95 percent had physicians, while in Montana only 47 percent were attended, loss of life due to isolation and lack of medical care is apparent. In sparsely settled regions the solution of this problem seems to demand the provision of local maternity hospitals, for the difficulty is primarily one of isolation.
Since medical science has shown that sparkling spring water may carry the deadly typhoid germ as a result of distant contamination, that wells are frequently contaminated by nearby privies or barn yards, that malaria is carried by mosquitoes, and that the house fly may carry typhoid fever and intestinal diseases of infants, we have come to appreciate that isolation and pure country air do not insure freedom from infection, and that sanitation is as important on the farm as in the city. Indeed the transmission of disease by flies is much easier on the farm, for too often the manure pile where they multiply is not far from the house, while in many a city the smaller number of horses and the cleaning of manure from the streets prevents their increase. The sanitation of the farm home thus becomes a very large factor in the health of the rural community. Surveys made by health officers in recent years have shown the general need of better sanitary provisions and also the possibility of the direct benefits secured from their improvement. In Indiana the State Board of Health surveyed nine typical rural counties taking only the homes on farms and in unincorporated villages. The average score of 6,124 rural homes in these nine counties was but 56.2 percent, the average for individual counties varying from 43 to 61 percent. In 1914, 1915, and 1916, the U. S. Public Health Service made sanitary surveys of 51,544 farm homes in 15 rural counties scattered throughout the United States, but mostly in the South. Its report[55] states that only 1.22 percent of these farm homes were equipped for a really sanitary disposal of human excreta, while in one county in Alabama less than 20 percent of the farm homes had toilets of any kind. "Sixty-eight percent of the water supply used for drinking or culinary purposes was obviously exposed to dangerous contamination from privy contents"; and only 32.88 percent of the houses were effectively screened against flies. A very considerable improvement in farm sanitation has resulted from the educational campaigns conducted during the past decade, but effective rural sanitation awaits the employment of public health officials who will convince the people of each local community of their individual responsibility for the health conditions on their own farms and of their common liability for the health of each other.
With the above conditions in mind, let us now consider the agencies for health conservation in rural communities. We have already seen that the old-fashioned country doctor is rapidly disappearing. With better transportation now available it seems probable that physicians will live in the larger village centers, but with telephone communication and the automobile it should be possible to secure as prompt medical attendance. We may as well recognize that many a rural community is too small a unit to support a resident physician and that if satisfactory medical treatment is to be secured we shall have to have better hospital and clinical facilities so that the time of the physician can be economized and frequent attention can be given.
Most rural townships have a local board of health and health officer, who is charged with reporting births and deaths and with the enforcement of quarantines against contagious diseases, but it is notorious that these local health officials are rarely efficient or take any leadership in the betterment of public health. Ordinarily the health officer receives little if any pay, and is a resident physician who is not inclined to antagonize his own clients when the enforcement of health regulations would meet their opposition. Students of rural health problems are now fairly agreed that the only means of securing efficient administration of public health regulations in rural communities is by the employment of a full time county health officer, working under a county board of health, who will have the same general duties as the health officers in our cities. Local health officers would be retained, but their work would be under the supervision of the county health officer and would have the benefit not only of his support and encouragement, but also of his superior technical training. If a county superintendent is necessary for our schools, a county health officer is equally necessary for the supervision of public health, and several states have enacted legislation requiring or permitting the employment of county health officers. The county is usually the best unit for rural health administration.[56] The county health officer would have laboratory facilities for the examination of drinking water, and samples of blood, urine, or sputum for the detection of disease, and would give direction for the taking of samples which might be sent to the laboratories of the state department of health for the examination of those specimens for which his laboratory was not equipped. He would have general supervision of the medical examination of school children. In numerous ways he would promote better means for health conservation, as can be done by one who has had special training for such work and who is giving his whole time and thought to its problems.